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Lopes HCB, Mazzolani BC, Koritar P, Cordás TA. Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review. Gen Hosp Psychiatry 2023; 85:43-54. [PMID: 37778285 DOI: 10.1016/j.genhosppsych.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN). METHODS This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS). RESULTS Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies. CONCLUSION All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.
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Affiliation(s)
- Helen Cristina Bittencourt Lopes
- Nutrition and Dietetics Service and Interdisciplinary Project for Care, Teaching, and Research on Eating Disorders in Childhood and Adolescence (PROTAD), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
| | - Bruna Caruso Mazzolani
- Applied Physiology & Nutrition Research Group and Laboratory of Assessment and Conditioning in Rhematology, University of São Paulo, São Paulo, Brazil.
| | - Priscila Koritar
- Nutrition and Dietetics Service, Barueri City Hall, São Paulo, SP, Brazil
| | - Táki Athanássios Cordás
- AMBULIM - Eating Disorders Program, Institute and Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
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McDonald CM, Alvarez JA, Bailey J, Bowser EK, Farnham K, Mangus M, Padula L, Porco K, Rozga M. Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2021; 121:1591-1636.e3. [PMID: 32565399 PMCID: PMC8542104 DOI: 10.1016/j.jand.2020.03.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 12/13/2022]
Abstract
The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.
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Verburgt CM, Ghiboub M, Benninga MA, de Jonge WJ, Van Limbergen JE. Nutritional Therapy Strategies in Pediatric Crohn's Disease. Nutrients 2021; 13:212. [PMID: 33450982 PMCID: PMC7828385 DOI: 10.3390/nu13010212] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 12/12/2022] Open
Abstract
The increase in incidences of pediatric Crohn's Disease (CD) worldwide has been strongly linked with dietary shifts towards a Westernized diet, ultimately leading to altered gut microbiota and disturbance in intestinal immunity and the metabolome. Multiple clinical studies in children with CD have demonstrated the high efficacy of nutritional therapy with exclusive enteral nutrition (EEN) to induce remission with an excellent safety profile. However, EEN is poorly tolerated, limiting its compliance and clinical application. This has spiked an interest in the development of alternative and better-tolerated nutritional therapy strategies. Several nutritional therapies have now been designed not only to treat the nutritional deficiencies seen in children with active CD but also to correct dysbiosis and reduce intestinal inflammation. In this review, we report the most recent insights regarding nutritional strategies in children with active CD: EEN, partial enteral nutrition (PEN), Crohn's disease exclusive diet (CDED), and CD treatment-with-eating diet (CD-TREAT). We describe their setup, efficacy, safety, and (dis)advantages as well as some of their potential mechanisms of action and perspectives. A better understanding of different nutritional therapeutic options and their mechanisms will yield better and safer management strategies for children with CD and may address the barriers and limitations of current strategies in children.
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Affiliation(s)
- Charlotte M. Verburgt
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
| | - Mohammed Ghiboub
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
| | - Wouter J. de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
- Department of Surgery, University of Bonn, 53127 Bonn, Germany
| | - Johan E. Van Limbergen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
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Sasaki Y, Akaba Y, Kajino H. Refeeding syndrome in a 12-year-old girl with distal renal tubular acidosis. Clin Case Rep 2020; 8:2682-2684. [PMID: 33363804 PMCID: PMC7752633 DOI: 10.1002/ccr3.3270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/19/2020] [Accepted: 08/01/2020] [Indexed: 11/18/2022] Open
Abstract
Distal renal tubular acidosis is a risk factor for refeeding syndrome. Frequent measurement of serum phosphorus levels at the initiation of nutrition and rapid administration of phosphate preparations are required to prevent organ failure.
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Affiliation(s)
- Yoshiaki Sasaki
- Department of PediatricsAbashiri‐Kosei General HospitalAbashiriJapan
| | - Yuichi Akaba
- Department of PediatricsAbashiri‐Kosei General HospitalAbashiriJapan
| | - Hiroki Kajino
- Department of PediatricsAbashiri‐Kosei General HospitalAbashiriJapan
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Parker E, Flood V, Halaki M, Wearne C, Anderson G, Gomes L, Clarke S, Wilson F, Russell J, Frig E, Kohn M. Study protocol for a randomised controlled trial investigating two different refeeding formulations to improve safety and efficacy of hospital management of adolescent and young adults admitted with anorexia nervosa. BMJ Open 2020; 10:e038242. [PMID: 33033021 PMCID: PMC7542921 DOI: 10.1136/bmjopen-2020-038242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Providing effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An 'underfeeding syndrome' can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15-25 years), hospitalised with AN. METHODS AND ANALYSIS The study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults with AN will be randomly allocated to commence feeding on a standard enteral feeding formula (1.5 kcal/mL, 54% carbohydrate) or a lower carbohydrate isocaloric enteral feeding formula (1.5 kcal/mL, 28% carbohydrate). Assessments of nutritional intake, weight and biochemistry (phosphate, magnesium, potassium) will be conducted at baseline and during the first 3 weeks of hospital admission. The primary outcome measure will be incidence of hypophosphatemia. Secondary outcomes include weight gain, oedema, other electrolyte distortion, length of hospital admission, admission to the Intensive Care Unit (ICU) and number of days to reach medical stability, using defined parameters. ETHICS AND DISSEMINATION The protocol was approved by the Western Sydney Local Health District Human Research Ethics Committee and institutional research governance approvals were granted. Written informed consent will be sought prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12617000342314); Pre-results.
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Affiliation(s)
- Elizabeth Parker
- Department of Dietetics & Nutrition, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Victoria Flood
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Allied Health Research Unit, Western Sydney Local Health District, Westmead Hospital, New South Wales, Australia
| | - Mark Halaki
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christine Wearne
- Department of Medical Psychology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Gail Anderson
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Linette Gomes
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Simon Clarke
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Centre for Research into Adolescents' Health (CRASH); Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Frances Wilson
- Department of Psychiatry, Westmead Hospital, Westmead, New South Wales, Australia
| | - Janice Russell
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- NSW Statewide Eating Disorder Service, Peter Beumont Unit, Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Elizabeth Frig
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael Kohn
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Centre for Research into Adolescents' Health (CRASH); Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Abstract
Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.
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Abstract
PURPOSE OF REVIEW Nutritional interventions play a central role in the treatment and management of inflammatory bowel disease (IBD) in children. Although malnutrition is a common presenting sign of IBD, nutritional interventions have focused not only on correction of the malnourished state but also on treatment of the primary disease. RECENT FINDINGS Exclusive enteral nutrition (EEN) has been the primary therapy utilized in pediatric IBD specifically, Crohn's disease. This intervention provides total calories from formula meeting complete macronutrient and micronutrient needs for a patient. EEN has been shown to improve growth and correct micronutrient deficiencies as well as improve comorbid conditions like osteopenia and anemia. EEN has also been shown to be equally as efficacious as steroids in inducing remission with better mucosal healing. SUMMARY EEN is a primary therapy in IBD. Both the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition consider EEN as first line therapy for inducing remission in Crohn's disease.
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8
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Day AS. The impact of exclusive enteral nutrition on the intestinal microbiota in inflammatory bowel disease. AIMS Microbiol 2018; 4:584-593. [PMID: 31294235 PMCID: PMC6613331 DOI: 10.3934/microbiol.2018.4.584] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022] Open
Abstract
It is increasingly clear that the intestinal microbiota plays key roles in the pathogenesis of the conditions known as Crohn disease and ulcerative colitis (jointly known as the inflammatory bowel diseases). Perturbations of the microbiota, termed dysbiosis, are present at diagnosis and likely reflect earlier environmental influences along with interactions with intestinal immune responses. Over the last two decades, there has been increasing interest in the use of a nutritional therapy to induce remission of active Crohn disease. Amongst a number of recent studies focusing on the putative mechanisms of action of enteral nutrition in Crohn disease, there have been several reports illustrating profound interactions between this nutritional therapy and the intestinal microbiota. Although at present it is still not clear how these changes relate to concurrent improvements in inflammation, it has become an area of increasing interest. This review article focuses on the impacts of nutritional therapy in individuals with active Crohn disease and overviews the most recent data arising from international studies.
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Affiliation(s)
- Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
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Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:687-708. [PMID: 29570147 DOI: 10.1097/mpg.0000000000001896] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients. METHODS A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature. RESULTS A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD. CONCLUSIONS This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.
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10
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Shaikhkhalil AK, Crandall W. Enteral Nutrition for Pediatric Crohn's Disease: An Underutilized Therapy. Nutr Clin Pract 2018; 33:493-509. [PMID: 29446858 DOI: 10.1002/ncp.10011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Enteral nutrition (EN) for the treatment of Crohn's disease (CD) involves administration of a liquid nutrition product, administered orally or through tube feeding, while excluding typical dietary components. It is a safe and effective, but largely underused, therapy in the United States as a treatment for CD. EN is a particularly attractive option for pediatric CD as it avoids side effects of corticosteroids, improves growth, and may have a higher likelihood of achieving mucosal healing than some traditional medications. However, there are multiple real and perceived barriers to its use among providers. A comprehensive approach to addressing these barriers to EN may result in its increased use. This paper reviews the literature on the efficacy of EN, methods of utilization, and potential barriers and solutions to those barriers.
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Affiliation(s)
- Ala K Shaikhkhalil
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Wallace Crandall
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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11
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Ashton JJ, Gavin J, Beattie RM. Exclusive enteral nutrition in Crohn's disease: Evidence and practicalities. Clin Nutr 2018; 38:80-89. [PMID: 29398336 DOI: 10.1016/j.clnu.2018.01.020] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/08/2017] [Accepted: 01/11/2018] [Indexed: 12/19/2022]
Abstract
Exclusive enteral nutrition (EEN) is the first line therapy for paediatric Crohn's disease, providing a complete nutritional feed whilst simultaneously inducing remission in up to 80% of cases. The effect of EEN on systemic/local intestinal immune function and subsequent inflammation (including barrier permeability, direct anti-inflammatory effects and cytokine signalling pathways), alongside changes in the microbiome (specific species and broad taxonomic shifts, functional changes) are becoming clearer, however the exact mechanism for induction of remission in Crohn's disease remains uncertain. The evidence of efficacy in paediatric Crohn's disease is strong, with selected adult populations also benefiting from EEN. However despite recommendations from all major societies (ECCO, ESPGHAN, NASPGHAN and ESPEN) first-line use of EEN is varied and Europe/Australasia/Canada show significantly more routine use than other parts of North America. Growth and nutritional status are significantly improved with EEN compared to corticosteroids but long-term outcomes are sparse. This review discusses the evidence underlying the use of EEN, highlighting the mechanisms thought to underlie how EEN induces remission in Crohn's disease, when and how to use EEN, including practical issues in both paediatric and adult practice (formulation, compliance, volumes and administration), and summarises the ongoing research priorities.
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Affiliation(s)
- James J Ashton
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK; Human Genetics and Genomic Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Joan Gavin
- Department of Paediatric Dietetics, Southampton Children's Hospital, Southampton, UK
| | - R Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.
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Swaminath A, Feathers A, Ananthakrishnan A, Falzon L, Ferry SL. Systematic review with meta-analysis: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease. Aliment Pharmacol Ther 2017; 46:645-656. [PMID: 28815649 PMCID: PMC5798240 DOI: 10.1111/apt.14253] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 03/30/2017] [Accepted: 07/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite potential adverse-events in a paediatric population, corticosteroids are used to induce remission in paediatric Crohn's disease. Exclusive enteral nutrition also induces remission, but is infrequently used in the USA because corticosteroids are considered the superior therapy. New data have become available since the publication of the most recent meta-analysis in 2007. AIM To see if current literature supports the use of EEN versus CS in paediatric populations. METHODS All studies with comparator arms of exclusive enteral nutrition and an exclusive corticosteroids, with remission clearly defined were identified by searching eight online databases. RESULTS Of 2795 identified sources, nine studies met our inclusion criteria. Eight of these (n = 451), had data that could be abstracted into our meta-analysis. Exclusive enteral nutrition was as effective as corticosteroids in inducing remission (OR = 1.26 [95% CI 0.77, 2.05]) in paediatric Crohn's disease. There was no difference between Exclusive enteral nutrition and corticosteroids efficacy when comparing newly diagnosed Crohn's (OR = 1.61 [95% CI .87, 2.98]) or relapsed (OR = 0.76 [95% CI .29-1.98]). Intestinal healing was significantly more likely among patients receiving Exclusive enteral nutrition compared to corticosteroids (OR = 4.5 [95% CI 1.64, 12.32]). There was no difference in the frequency of biomarker normalisation including CRP (OR = 0.85 [95% CI .44, 1.67]) and faecal calprotectin (OR 2.79 [95% CI .79-10.90]). CONCLUSIONS There is no difference in efficacy between exclusive enteral nutrition and corticosteroids in induction of remission in Crohn's disease in a paediatric population. Exploratory analyses suggest that a greater proportion of patients treated with exclusive enteral nutrition achieved mucosal healing.
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Affiliation(s)
- Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY,
USA
| | | | | | - Louise Falzon
- Columbia University Medical Center, New York, NY, USA
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13
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El Shazly AN, Soliman DR, Assar EH, Behiry EG, Gad Ahmed IAEN. Phosphate disturbance in critically ill children: Incidence, associated risk factors and clinical outcomes. Ann Med Surg (Lond) 2017; 21:118-123. [PMID: 28861270 PMCID: PMC5560116 DOI: 10.1016/j.amsu.2017.07.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/30/2017] [Accepted: 07/30/2017] [Indexed: 11/26/2022] Open
Abstract
Background Hypophosphatemia is one of the common disorders that develop in critically ill patients. It has potential complications and is often unrecognized in those patients. Objective Determining the incidence of hypophosphatemia in critically ill children, its association with clinical outcomes and the possible risk factors. Methods 50 patients were enrolled in the study. Levels of serum phosphate were measured on day 1 and day 7 of PICU (Pediatric intensive care unit) stay. The following variables were analyzed: age, gender, diagnosis on admission, malnutrition, phosphorus intake, clinical severity score on admission OFI (Organ Failure Index) and daily scores PELOD (Pediatric Logistic Organ Dysfunction), sepsis, use of dopamine, furosemide and steroids and assessment of nutrition by z scores. Results The incidence of hypophosphatemia on admission was 42%. On seventh day of admission incidence of hypophosphatemia was 62%. Malnutrition was present in 24% of patients, serum phosphorus level was significantly lower in malnourished than in well-nourished children (p value = 0.018). Hypophosphatemia was associated with prolonged PICU length of stay (p < 0.001) but was not associated with increased mortality (p = 0.13). Cases on parenteral nutrition and insufficient oral intake while on mechanical ventilator significantly showed hypophosphatemia (p = 0.017). Hypophosphatemia was associated with the use of furosemide, dopamine, steroids and β2 agonist. Conclusion Hypophosphatemia was common in the first 7 days of PICU hospitalization and was associated with prolonged PICU stay, Significant association between hypophosphatemia and duration of use of mechanical ventilation, use of furosemide, dopamine, steroids and β2 agonist. Hypophosphatemia was common in the first 7 days of pediatric intensive care unit hospitalization. Significant association between hypophosphatemia and duration of use of mechanical ventilation. Hypophosphatemia was associated with prolonged pediatric intensive care unit length of stay. Hypophosphatemia was associated with use of furosemide, dopamine, steroid and β2 agonist. Good nutrition of critically ill children has an important role in improving their clinical condition.
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Affiliation(s)
- Ahmed Nabih El Shazly
- Department of Pediatrics, Faculty of Medicine, Benha University, Benha Qualubia, 13511, Egypt
| | - Doaa Refaey Soliman
- Department of Pediatrics, Faculty of Medicine, Benha University, Benha Qualubia, 13511, Egypt
| | - Effat Hussien Assar
- Department of Pediatrics, Faculty of Medicine, Benha University, Toukh Qualubia, 13471, Egypt
| | - Eman Gamal Behiry
- Department of Pediatrics, Faculty of Medicine, Benha University, Benha Qualubia, 13511, Egypt
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14
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Beattie RM. Enteral Nutrition as Primary Therapy in Childhood Crohn's Disease: Control of Intestinal Inflammation and Anabolic Response. JPEN J Parenter Enteral Nutr 2016; 29:S151-5; discussion S155-9, S184-8. [PMID: 15980277 DOI: 10.1177/01486071050290s4s151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Crohn's disease in childhood is a chronic relapsing and remitting condition that can significantly impact normal growth and development. This influences choice of both initial and ongoing management. The goal of therapy is to induce and maintain remission with minimal side effects. Enteral nutrition is effective in active disease and will induce disease remission in most cases avoiding corticosteroid use. The high frequency of relapse means additional immunosuppressive therapies are usually required but nutrition remains a key priority as part of the subsequent management strategy.
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Affiliation(s)
- Robert M Beattie
- Pediatric Medical Unit, Southampton General Hospital, Tremona Road, Southampton, United Kingdom.
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15
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Jahn HK, Barraclough S, Currell S, Tighe MP. Febrile neutropenia and refeeding syndrome. Arch Dis Child Educ Pract Ed 2016; 101:296-303. [PMID: 27389547 DOI: 10.1136/archdischild-2015-308850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 05/16/2016] [Accepted: 06/13/2016] [Indexed: 11/04/2022]
Abstract
We describe the management of a 4-year-old child with acute lymphoblastic leukaemia (ALL) who presented with febrile neutropenia, Cryptosporidium and subsequently developed refeeding syndrome. Febrile neutropenia is common and can be life-threatening and we highlight the identification of well low-risk neutropenic children with resolved febrile illnesses suitable for early discharge. We also discuss the potential management strategies for Cryptosporidium Refeeding syndrome is not common, but should be considered as a cause of acute inpatient deterioration and is a significant risk, with potential morbidity, in children who have undergone a period of catabolism. This article reviews the current literature and provides useful guidance on these issues.
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Affiliation(s)
- H K Jahn
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - S Barraclough
- Paediatric Department, Poole Hospital NHS Trust, Poole, UK
| | - S Currell
- Paediatric Department, Poole Hospital NHS Trust, Poole, UK
| | - M P Tighe
- Paediatric Department, Poole Hospital NHS Trust, Poole, UK
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Bortolotti M, Ventura G, Jegatheesan P, Choisy C, Cynober L, De Bandt JP. Impact of qualitative and quantitative variations in nitrogen supply on catch-up growth in food-deprived-refed young rats. Clin Nutr 2016; 35:669-78. [DOI: 10.1016/j.clnu.2015.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/09/2015] [Accepted: 04/22/2015] [Indexed: 02/07/2023]
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Shenoy J, Adapala RKR. Study of Feeding Jejunostomy as an Add on Procedure in Upper Gastrointestinal Surgeries. Indian J Surg 2016; 77:275-82. [PMID: 26730009 DOI: 10.1007/s12262-012-0795-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 12/02/2012] [Indexed: 12/26/2022] Open
Abstract
Jejunostomy is usually indicated as an additional procedure during major surgery of upper digestive tract to administer enteral nutrition in post-operative period. Complications associated with it can be mechanical, infectious, gastrointestinal or metabolic. The aim of the study was to evaluate safety of post-operative feeding jejunostomy in different types of major upper gastrointestinal surgeries. It was a prospective study conducted during the period between August 2009 and September 2011. Post-operative cases of major upper gastrointestinal surgeries who receive jejunostomy feeds were included in the study. Sampling was done by convenient method with sample size of 50 cases. Post-operatively, patients were monitored according to standard orders of enteral nutrition. Total calorie and protein intake through feeding jejunostomy was calculated regularly, and complications were assessed in terms of frequency, type, duration, management, and final outcome in different types of upper gastro intestinal surgeries. Analysis was done using chi square test with the help of statistical package SPSS vers.13. P < 0.05 was considered as significant. Complications observed were gastrointestinal -8 (16 %), mechanical -6 (12 %), infectious -4 (8 %) and metabolic -4 (8 %). Duration of complications ranged from 1 to 7 days (mean, 4 days). All types of complications observed during study were less severe and could be managed by simple measurements. Haemoglobin, serum albumin and weight of the patient at the time of discharge were improved for all patients when compared to pre-operative values. All patients received target calories and proteins through feeding jejunostomy. Considering benefits of enteral feeding via jejunostomy tube with minor and acceptable complications, we conclude that feeding jejunostomy is a preferred route of nutritional administration in those who undergo major upper gastro intestinal surgeries.
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Affiliation(s)
- Jayarama Shenoy
- Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, India
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Abstract
Medical providers need to monitor growth at every visit. Weight status is influenced by genetics, medical conditions, socioeconomic status, and family environment. Screening for food security and psychosocial risk factors is an integral tool to identify families at risk for nutritional deficits and child maltreatment. Nutritional rehabilitation is best accomplished in an outpatient, multidisciplinary setting. Medical neglect should be considered in failure to thrive and obesity when there is a serious risk of harm from identified medical complications, additional or worsening medical complications occurring despite a multidisciplinary approach, and/or non-adherence with the treatment plan.
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Affiliation(s)
- Nancy S Harper
- Children's Physician Services of South Texas, Driscoll Children's Hospital, 3533 South Alameda, Corpus Christi, TX 78411, USA.
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Impact of the Early Initiation of Feedings on Hospital Length of Stay in Children Post–PEG Tube Placement. Gastroenterol Nurs 2014; 37:344-9. [DOI: 10.1097/sga.0000000000000065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Prevalence of undernutrition during hospitalisation in a children’s hospital: what happens during admission? Eur J Clin Nutr 2014; 68:730-5. [DOI: 10.1038/ejcn.2014.21] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 01/04/2014] [Accepted: 01/14/2014] [Indexed: 11/08/2022]
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Day AS, Burgess L. Exclusive enteral nutrition and induction of remission of active Crohn's disease in children. Expert Rev Clin Immunol 2013; 9:375-83; quiz 384. [PMID: 23557272 DOI: 10.1586/eci.13.12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Exclusive enteral nutrition is an effective therapy for the management of active Crohn's disease, especially in children and adolescents. This therapeutic approach involves the use of a liquid nutritional product with the exclusion of normal diet for a period of many weeks. Although recent studies have helped to delineate some aspects of how exclusive enteral nutrition should be used, there remain many gaps in our understanding. In addition, several recent reports have provided intriguing insights into the mechanisms of this nutritional approach.
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Affiliation(s)
- Andrew S Day
- Department of Paediatrics, University of Otago (Christchurch), Christchurch Hospital, Christchurch, New Zealand.
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Hudson LD, Court AJ. What paediatricians should know about eating disorders in children and young people. J Paediatr Child Health 2012; 48:869-75. [PMID: 22404762 DOI: 10.1111/j.1440-1754.2012.02433.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Any health professional working with children and young people may become involved in the care of a child or young person with an eating disorder. Morbidity and mortality can be high, and paediatricians have an important role to play. There are broadly two aspects of underweight that the paediatrician may face - acute medical instability and a more chronic underweight which can impact greatly upon growth and development. Ultimate weight restoration means an adequate nutritional status to allow appropriate growth and development. Key to success is a team approach with paediatric and mental health and dietetic expertise combined. This paper provides an overview of eating disorders and explores current best practice, written in collaboration by a paediatrician and child and adolescent psychiatrist.
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Affiliation(s)
- Lee D Hudson
- Department Child and Adolescent Psychiatry, Feeding and Eating Disorders Team, Great Ormond Street Hospital, London, United Kingdom.
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Dror Y, Almashanu S, Lubart E, Sela BA, Shimoni L, Segal R. The Impact of Refeeding on Blood Fatty Acids and Amino Acid Profiles in Elderly Patients. JPEN J Parenter Enteral Nutr 2012; 37:109-16. [DOI: 10.1177/0148607112443260] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Yosef Dror
- School of Nutrition, Faculty of Agriculture, The Hebrew University of Jerusalem, Rehovot, Tel-Hashomer, Israel
| | - Shlomo Almashanu
- Department of Community Genetics, Israeli Ministry of Health, Tel-Hashomer, Israel
| | - Emilia Lubart
- Geriatric Medical Center, Shmuel Harofeh, Beer Yaakov, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ben-Ami Sela
- The Sackler Faculty of Medicine, Tel Aviv University, Israel
- Institute of Chemical Pathology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Liron Shimoni
- School of Nutrition, Faculty of Agriculture, The Hebrew University of Jerusalem, Rehovot, Tel-Hashomer, Israel
| | - Refael Segal
- Geriatric Medical Center, Shmuel Harofeh, Beer Yaakov, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Israel
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Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease. J Pediatr Gastroenterol Nutr 2012; 54:298-305. [PMID: 22002478 DOI: 10.1097/mpg.0b013e318235b397] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Exclusive enteral nutrition is an effective yet often underused therapy for the induction of remission in pediatric Crohn disease. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition formed the Enteral Nutrition Working Group to review the use of enteral nutrition therapy in pediatric Crohn disease. The group was composed of 5 pediatric gastroenterologists and 1 pediatric nutritionist, all with an interest and/or expertise in exclusive enteral nutrition. Specific attention was placed upon review of the evidence for efficacy of therapy, assessment of the variations in care, identification of barriers to its widespread use, and compilation of the necessary components for a successful program. The present guideline is intended to aid physicians in developing an enteral nutrition therapy program and potentially promote its use.
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Tighe MP, Cummings JRF, Afzal NA. Nutrition and inflammatory bowel disease: primary or adjuvant therapy. Curr Opin Clin Nutr Metab Care 2011; 14:491-6. [PMID: 21832904 DOI: 10.1097/mco.0b013e328349eb4d] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Our understanding of the importance of nutrition in inflammatory bowel disease (IBD) continues to improve. With increasing evidence or cumulative evidence, this article reviews the current data for the role of nutrition in IBD pathogenesis, disease exacerbation and its use in the treatment of IBD in a clinically relevant context. RECENT FINDINGS Irritable bowel syndrome and obesity prevalence is rising, and is increasingly being recognized in patients with IBD. Exclusive enteral nutrition remains highly relevant because of its efficacy and superior side-effect profile, even when considered against new pharmacological treatments, but requires patient motivation. We are now beginning to understand the importance of micronutrients such as iron and vitamin D, which may not only alter the bowel flora but also have an immune-modulatory effect. More recently, a prebiotic and probiotic combination has been used in a randomized trial for the treatment of IBD. SUMMARY Macronutrient and micronutrient assessment should be an essential part of nutritional assessment of all patients with IBD. Although research is needed to further our understanding of the immune-modulatory effects of nutrients and supplements, better and more effective therapies combining nutrition and drug treatments like immune-suppressants should be explored.
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Affiliation(s)
- Mark P Tighe
- Department of Paediatrics, Poole Hospital NHS Trust, Poole, UK
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Nützenadel W. Failure to thrive in childhood. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:642-9. [PMID: 22025931 PMCID: PMC3198227 DOI: 10.3238/arztebl.2011.0642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 12/28/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Failure to thrive impairs children's weight gain and growth, their defenses against infection, and their psychomotor and intellectual development. METHODS This paper is a review of pertinent articles that were published from 1995 to October 2010 and contained the terms "failure to thrive", "underweight", "malnutrition", "malabsorption", "maldigestion" and "refeeding syndrome". The articles were retrieved by a search in the PubMed and Cochrane Library databases. RESULTS In developed countries, failure to thrive is usually due to an underlying disease. The degree of malnutrition is assessed with anthropometric techniques. For each patient, the underlying disease must be identified and the mechanism of failure to thrive understood, so that proper medical and nutritional treatment can be provided. Nutritional treatment involves either giving more food, or else raising the caloric density of the patient's food. Liquid formulas can be given as a supplement to normal meals or as balanced or unbalanced tube feeds; they can be given orally, through a nasogastric tube, or through a gastrostomy tube. Severely malnourished children with poor oral intake should be treated with parenteral nutrition. To avoid refeeding syndrome in severely malnourished children, food intake should be increased slowly at first, and phosphate, magnesium, and potassium supplements should be given. CONCLUSION The proper treatment of failure to thrive in childhood consists of treatment of the underlying illness, combined with nutritional treatment that addresses the mechanism of the accompanying failure to thrive.
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Affiliation(s)
- Walter Nützenadel
- Klinikum Mannheim GmbH, Universitätsklinikum, Klinik für Kinder- und Jugendmedizin.
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Abstract
OBJECTIVE A 10-year-old girl with anorexia nervosa developed the refeeding syndrome following cautious reintroduction of nutrition, emphasizing that even with cautious refeeding a shift in fluid, glucose, and electrolytes can still occur, increasing the risk of morbidity and mortality in this ever growing vulnerable group. METHOD Biochemical, nutritional, and anthropometrical monitoring in the patient, who followed a conservative refeeding program after a prolonged period of nutritional inadequacy. RESULTS The refeeding syndrome presented itself with hypophosphatemia, hypotension, and cardiac abnormalities whilst refeeding at 25 kcal/kg (600 kcal/day). DISCUSSION Comprises of a literature review, highlighting this case as the youngest reported case of refeeding syndrome in anorexia nervosa. Discussion focuses on the possible deleterious affects that carbohydrates may have in exacerbating the refeeding syndrome.
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Affiliation(s)
- Graeme O'Connor
- Division of Nutrition and Dietetics, Great Ormond Street Children's Hospital, London, United Kingdom.
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Transient hypertransaminasemia in paediatric patients with Crohn disease undergoing initial treatment with enteral nutrition. J Pediatr Gastroenterol Nutr 2010; 51:336-40. [PMID: 20601906 DOI: 10.1097/mpg.0b013e3181d94f63] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Total enteral nutrition (TEN) is frequently used as monotherapy in children with Crohn disease to prevent steroid toxicity. Liver disease is a known complication in inflammatory bowel disease, and liver enzymes are regularly obtained in these patients. PATIENTS AND METHODS Prospective follow-up of liver enzymes was performed in 11 new consecutive patients ages 7.6 to 17.1 years who were primarily treated with TEN for 6 weeks. Liver enzymes were measured before starting TEN and after 3, 6, and 12 weeks. RESULTS At the beginning of TEN, the mean aspartate aminotransferase (ASAT) was 18.4 U/L and the mean alanine aminotransferase (ALAT) 17.1 U/L. The mean ASAT and ALAT were 202.0 U/L and 269.0 U/L after 3 weeks and 109.6 U/L and 180.9 U/L at 6 weeks. After 12 weeks values decreased to 22.8 U/L (ASAT) and 20.9 U/L (ALAT). Overall, 9 of 11 patients had transient elevated ASAT and 10 patients showed elevated ALAT. Gamma-glutamyl transpeptidase was slightly elevated in 3 patients during therapy, but alkaline phosphatase and bilirubin showed no changes. None of the patients developed liver disease during follow-up, and prolonged clinical remission was achieved in 9 patients. CONCLUSIONS This study shows that TEN can be associated with transient hypertransaminasemia without evidence of liver disease. We hypothesise that insulin resistance in patients with Crohn disease in combination with standard TEN formulae can result in transient hepatic steatosis causing the hypertransaminasemia. For the clinician it is important to be aware of this benign TEN-associated condition to prevent unnecessary investigations.
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Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2010; 51:110-22. [PMID: 20453670 DOI: 10.1097/mpg.0b013e3181d336d2] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.
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Boateng AA, Sriram K, Meguid MM, Crook M. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition 2010; 26:156-67. [PMID: 20122539 DOI: 10.1016/j.nut.2009.11.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/17/2009] [Accepted: 11/23/2009] [Indexed: 12/14/2022]
Abstract
Refeeding syndrome (RFS) represents a group of clinical findings that occur in severely malnourished individuals undergoing nutritional support. Cardiac arrhythmias, multisystem organ dysfunction, and death are the most severe symptoms observed. As the cachectic body attempts to reverse its adaptation to the starved state in response to the nutritional load, symptoms result from fluid and electrolyte imbalances, with hypophosphatemia playing a central role. Because guidelines for feeding the malnourished patient at risk for refeeding syndrome is scarce, we have provided management recommendations based on the knowledge derived from a collection of reported English literature cases of the RFS. A MEDLINE search using keywords including "refeeding syndrome," "RFS," and "refeeding hypophosphatemia" was performed. References from initial cases were utilized for more literature on the subject. We have emphasized the continued importance of managing patients at risk for RFS, compared how management of the severely malnourished patients have evolved over time, and provided comprehensive clinical guidelines based on the sum of experience documented in the case reports for the purpose of supplementing the guidelines available. Based on our review, the most effective means of preventing or treating RFS were the following: recognizing the patients at risk; providing adequate electrolyte, vitamin, and micronutrient supplementation; careful fluid resuscitation; cautious and gradual energy restoration; and monitoring of critical laboratory indices.
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Affiliation(s)
- Akwasi Afriyie Boateng
- Surgical Metabolism and Nutrition Laboratory, Department of Surgery, University Hospital, Upstate Medical University, State University of New York, Syracuse, NY 13210, USA
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Systematic review of the evidence base for the medical treatment of paediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2010; 50 Suppl 1:S14-34. [PMID: 20081542 DOI: 10.1097/mpg.0b013e3181c92caa] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To systematically review the evidence base for the medical (pharmaceutical and nutritional) treatment of paediatric inflammatory bowel disease. METHODS Key clinical questions were formulated regarding different treatment modalities used in the treatment of paediatric (not adult-onset) IBD, in particular the induction and maintenance of remission in Crohn disease and ulcerative colitis. Electronic searches were performed from January 1966 to December 2006, using the electronic search strategy of the Cochrane IBD group. Details of papers were entered on a dedicated database, reviewed in abstract form, and disseminated in full for appraisal. Clinical guidelines were appraised using the AGREE instrument and all other relevant papers were appraised using Scottish Intercollegiate Guidelines Network methodology, with evidence levels given to all papers. RESULTS A total of 6285 papers were identified, of which 1255 involved children; these were entered on the database. After critical appraisal, only 103 publications met our criteria as evidence on medical treatment of paediatric IBD. We identified 3 clinical guidelines, 1 systematic review, and 16 randomised controlled trials; all were of variable quality, with none getting the highest methodological scores. CONCLUSIONS This is the first comprehensive review of the evidence base for the treatment of paediatric IBD, highlighting the paucity of trials of high methodological quality. As a result, the development of clinical guidelines for managing children and young people with IBD must be consensus based, informed by the best-available evidence from the paediatric literature and high-quality data from the adult IBD literature, together with the clinical expertise and multidisciplinary experience of paediatric IBD experts.
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Hartman C, Eliakim R, Shamir R. Nutritional status and nutritional therapy in inflammatory bowel diseases. World J Gastroenterol 2009; 15:2570-8. [PMID: 19496185 PMCID: PMC2691486 DOI: 10.3748/wjg.15.2570] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease (IBD). In addition, a significant number of children with IBD, especially Crohn’s disease (CD) have impaired linear growth. Nutrition has an important role in the management of IBD. In adults with CD, enteral nutrition (EN) is effective in inducing clinical remission of IBD, although it is less efficient than corticosteroids. Exclusive EN is an established primary therapy for pediatric CD. Limited data suggests that EN is as efficient as corticosteroids for induction of remission. Additional advantages of nutritional therapy are control of inflammation, mucosal healing, positive benefits to growth and overall nutritional status with minimal adverse effects. The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD. More studies are needed to confirm these findings. However, EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD. EN does not have a primary therapeutic role in ulcerative colitis. Specific compositions of enteral diets-elemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation. Recent theories suggest that diet may be implicated in the etiology of IBD, however there are no proven dietary approaches to reduce the risk of developing IBD.
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Patel U, Sriram K. Acute respiratory failure due to refeeding syndrome and hypophosphatemia induced by hypocaloric enteral nutrition. Nutrition 2009; 25:364-7. [DOI: 10.1016/j.nut.2008.09.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 07/12/2008] [Accepted: 09/18/2008] [Indexed: 01/30/2023]
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Abstract
BACKGROUND Hypophosphatemia is a disorder with potential complications and is often unrecognized in critically ill patients. AIMS To identify the prevalence of hypophosphatemia and risk factors associated to this disorder in critically ill children. METHODS In a prospective cohort study, 82 children admitted consecutively to a pediatric intensive care unit (ICU) were monitored regarding phosphorus serum levels during the first 10 days of admission. The following variables were analyzed as independent for hypophosphatemia: age, gender, diagnosis at admission, malnutrition, phosphorus intake, clinical severity score at admission (pediatric index of mortality 2) and daily scores (Pediatric Logistic Organ Dysfunction), sepsis, use of dopamine, furosemide and steroids, starvation period, and refeeding. Children with a z score of less than -2 of expected weight for age or body mass index (National Center for Health Statistics, 2000) were considered malnourished. Variables significantly associated with hypophosphatemia by bivariate analysis (p < 0.1) were included in a multiple logistic regression model. RESULTS The rate of hypophosphatemia was 61% during the first 10 days of pediatric ICU stay, and 12 patients developed hypophosphatemia during the study period. Malnutrition was present in 39.1% of patients, and the sera phosphorus concentration was significantly lower in malnourished than in well-nourished children (2.6 +/- 0.7 mg/dL vs. 3.5 +/- 0.8 mg/dL, p = 0.01). The multiple logistic regression model indicated the diagnosis of acute respiratory disease (odds ratio: 3.22; confidence interval: 1.03-10.1; p = 0.04), use of dopamine (odds ratio: 8.65; confidence interval: 1.58-47.3; p = 0.01), and malnutrition (odds ratio: 3.96; confidence interval: 1.19-13.3; p = 0.02) as independent risk factors for hypophosphatemia. None of the other potential risk factors discriminated for hypophosphatemia. CONCLUSIONS Hypophosphatemia was common in the first 10 days of ICU hospitalization and was associated with the diagnosis of respiratory disease, use of dopamine, and malnutrition. These factors should be taken into account during clinical follow up of critically ill children, especially when these conditions are found together.
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Refeeding syndrome: recognition is the key to prevention and management. ACTA ACUST UNITED AC 2009; 108:2105-8. [PMID: 19027417 DOI: 10.1016/j.jada.2008.09.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Accepted: 06/25/2008] [Indexed: 12/27/2022]
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Charney P. Nutrition Screening vs Nutrition Assessment: How Do They Differ? Nutr Clin Pract 2008; 23:366-72. [DOI: 10.1177/0884533608321131] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
If your patient is malnourished, you need to assess her carefully before she restarts nutrition by any route to avoid potentially lethal consequences.
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Affiliation(s)
- Mary Ann Yantis
- Louise Herrington School of Nursing, Baylor University in Dallas, TX, USA
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Miller SJ. Death Resulting From Overzealous Total Parenteral Nutrition: The Refeeding Syndrome Revisited. Nutr Clin Pract 2008; 23:166-71. [DOI: 10.1177/0884533608314538] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sarah J. Miller
- From the Department of Pharmacy Practice, University of Montana, Missoula
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Day AS, Whitten KE, Sidler M, Lemberg DA. Systematic review: nutritional therapy in paediatric Crohn's disease. Aliment Pharmacol Ther 2008; 27:293-307. [PMID: 18045244 DOI: 10.1111/j.1365-2036.2007.03578.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND At least 25% of individuals diagnosed with Crohn's disease (CD) have onset of disease in childhood. Almost all children with CD have nutritional impairments, such as weight loss or stunting, at diagnosis or subsequently. Nutritional therapy (exclusive enteral nutrition) is established as a valid and effective treatment in paediatric CD. The advantages of this approach are induction of remission and control of inflammatory changes, mucosal healing, positive benefits to growth and overall nutritional status, and avoidance of other medical therapies. AIM To provide a comprehensive up-to-date review of the roles of nutritional therapy in CD and of the data supporting this therapy. METHODS A search of PubMed was performed with search terms 'enteral nutrition', 'nutritional therapy', 'Crohn disease' and 'children'. Relevant articles were selected from this search. In addition, the reference lists of available articles were reviewed for further relevant articles. RESULTS Nutritional therapy offers numerous benefits in the management of CD. Recent work has begun to elucidate the likely mechanisms of this therapy. These include direct mucosal anti-inflammatory effects and alteration of intestinal microflora. CONCLUSION Further studies are required to define longer-term effects of nutritional therapy in patients with CD.
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Affiliation(s)
- A S Day
- Department of Gastroenterology, Sydney Children's Hospital, Sydney, Australia.
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de Menezes FS, Leite HP, Fernandez J, Benzecry SG, de Carvalho WB. Hypophosphatemia in children hospitalized within an intensive care unit. J Intensive Care Med 2006; 21:235-9. [PMID: 16855058 DOI: 10.1177/0885066606287081] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aims of this study were to estimate the occurrence of hypophosphatemia and to identify potential risk factors and outcome measures associated with this disturbance in children admitted to a pediatric intensive care unit. Data concerning 42 children admitted consecutively to 1 pediatric intensive care unit over a 1-year period were examined. Serum phosphorus levels were measured on the third day of admission, where levels below 3.8 mg/dL were considered indicative of hypophosphatemia. Hypophosphatemia was found in 32 children (76%), and there was a significant association between this disturbance and malnutrition (P = .04). Of the potential risk factors such as sepsis, diuretic/steroid therapy, starvation (over 3 days), and Pediatric Index of Mortality, none discriminated for hypophosphatemia. There were no associations between hypophosphatemia and mortality, length of stay in the pediatric intensive care unit, or time on mechanical lung ventilation. Hypophosphatemia was a common finding in critically ill children and was associated with malnutrition.
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Armitage-Chan EA, O'Toole T, Chan DL. Management of prolonged food deprivation, hypothermia, and refeeding syndrome in a cat. J Vet Emerg Crit Care (San Antonio) 2006. [DOI: 10.1111/j.1476-4431.2006.00132.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Roulet M, Cheseaux M, Coti P. Conséquences de la dénutrition chez l'enfant et l'adolescent. Mortalité, morbidité, conséquences médicoéconomiques. NUTR CLIN METAB 2005. [DOI: 10.1016/j.nupar.2005.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Gavin J, Anderson CE, Bremner AR, Beattie RM. Energy intakes of children with Crohn's disease treated with enteral nutrition as primary therapy. J Hum Nutr Diet 2005; 18:337-42. [PMID: 16150129 DOI: 10.1111/j.1365-277x.2005.00631.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enteral nutrition (EN) is widely used and is effective in the treatment of children with Crohn's disease given as an exclusive feed for 6-8 weeks. Current dietetic practice during EN is to recommend an energy intake based on estimated average requirement (EAR) for energy for age. AIMS To examine factors affecting energy intake and weight gain during EN in relation to disease site and nutritional status. METHODS A retrospective cohort study examining energy intake and weight gain during the exclusive EN feeding period in 40 patients newly diagnosed with Crohn's in relation to EAR, nutritional status, disease site. RESULTS All patients improved clinically and gained weight during EN with improvement in the CRP as a marker of the systemic inflammatory response. Energy intake was higher than EAR in 82% (33/40 patients), with the median 117.5% of EAR. Weight gain correlated with body mass index standard deviation score (P = 0.001) at start of treatment, but not energy intake or CRP. CONCLUSION Estimated average requirement underestimates energy intakes in most children with newly diagnosed Crohn's disease. During EN, an energy intake in the range of 100-149% (median 117.5%) EAR for energy for age may be required. Energy balance studies in children with active disease are required.
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Affiliation(s)
- J Gavin
- Department of Nutrition and Dietetics, Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, UK.
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Temprano Ferreras JL, Bretón Lesmes I, de la Cuerda Compés C, Camblor Alvarez M, Zugasti Murillo A, García Peris P. Síndrome de realimentación. Revisión. Rev Clin Esp 2005; 205:79-86. [PMID: 15766481 DOI: 10.1157/13072501] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Refeeding syndrome is a complex clinical picture that encompass all those alterations that can occur as a consequence of the nutritional support (oral, enteral or parenteral) in malnourished patients. Refeeding syndrome is classically characterized by neurological alterations, respiratory symptoms, cardiac arrhythmias and heart failure few days after beginning of refeeding, with life-threatening outcome. Its pathogenesis includes alterations in the corporal fluids, and in some electrolytes, minerals and vitamins. In this article a review of refeeding syndrome pathogenesis and clinical manifestations is carried out, with a final series of recommendations for lowering the risk of this syndrome and for facilitate the early diagnosis and the treatment.
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Georges B, Thissen JP, Lambert M. Severe hypophosphatemia in a patient with anorexia nervosa during enteral refeeding. Acta Clin Belg 2004; 59:361-4. [PMID: 15819381 DOI: 10.1179/acb.2004.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Hypophosphatemia is a seldom but potentially fatal complication of the nutritional recovery or refeeding syndrome in patients with protein-calorie malnutrition or starvation. We report here the case of a 35-year-old anorexic patient who presented a severe but uncomplicated hypophosphatemia during enteral refeeding, despite phosphorus supplementation. Serum phosphorus monitoring is recommended in severely malnourished anorexic patients, particularly during the first week of refeeding, be it parenteral or enteral.
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Affiliation(s)
- B Georges
- Division of General Internal Medicine, Saint-Luc University Hospital, Brussels
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